Approximately 1 million persons in the United States
receive long-term oxygen therapy (LTOT) annually through
the Medicare program, most often for smoking-related lung disease
(1,2). At 2:10 a.m. on December 14, 2007, a fire
occurred in a public housing project for the elderly in Westbrook, Maine. Approximately 60 residents were evacuated; six were
transported to a hospital for smoke inhalation. The fire was caused unintentionally by a woman aged 57 years who was an overnight
guest of a relative who lived in the housing project. The visitor had ignited the fire while simultaneously smoking and using
an oxygen concentrator.* After this incident, the Maine Department of Health and Human Services, in collaboration with
three other states, attempted to determine 1) how often this type of event results in fatalities and 2) factors common to
these incidents that might be amenable to prevention. This report describes the results of that study, which found that,
during 2000--2007, of the 38 deaths identified in the four states, 37 occurred in private residences, and the median age of
the
decedents was 67 years. Prevention of this type of fatality is dependent on smoking cessation, careful assessment of the
need for LTOT, and strategies to prevent injuries from fires, such as smoke alarms and sprinklers.

Three other states (Massachusetts, New Hampshire, and Oklahoma) agreed to join Maine in the study. A case was
defined as a fatality resulting from a fire caused by smoking during LTOT by a resident of one of the four states during 2000--2007.
In Maine, Massachusetts, and New Hampshire, cases were identified by state fire marshals, based on information provided
by immediate survivors and household members and investigation of the scene by fire officials. Supplementary information
for certain cases was available from medical examiners, death certificates, and newspaper accounts. In Oklahoma, cases
were identified using the state burn registry, which relies on multiple data sources, including medical
examiner reports, burn center medical records, fire marshal and fire department reports, and media accounts
(3). Burns and smoke inhalation injuries resulting in hospitalization or death have been a reportable condition in Oklahoma since 1986 but have not been reportable
in the other three states.

A total of 38 cases were identified: five in Maine, three in New Hampshire, 11 in Massachusetts, and 19 in Oklahoma.
All incidents involved a single fatality except for one fire that resulted in two deaths. The overall fatality rate for the four states
was 3.8 deaths per 10 million population per year. The highest fatality rate was in Oklahoma (6.7 per 10 million
population), followed by Maine (4.8), New Hampshire (2.9), and Massachusetts (2.1). Decedents ranged in age from 9 to 87
years (median: 67 years); the death of a child aged 9 years was the only fatality involving a minor. Twenty-four (63%)
decedents were female. Thirty-four (89%) of the decedents were on LTOT and were smoking at the time the fire began; three (8%)
were household members of smokers on LTOT who survived, and one (3%) was a nonsmoker on LTOT who was
unintentionally ignited by a smoker who lived in the household and survived. Twenty-two (58%) decedents died on the day of the fire,
and seven (18%) died the following day. The remaining nine (24%) decedents survived a median of 15 days (range: 3--41 days).

All 38 fatalities occurred in private residences except for one in a nursing home. Ten (27%) incidents occurred
in multifamily dwellings; six (16%) occurred in mobile homes. For the 27 incidents for which location in the home was
known, 14 (52%) fires began in a bedroom, 11 (41%) in a living room, one (4%) in a hallway, and one (4%) in a bathroom.
House fires occurred in 24 (65%) incidents; the remaining fires were confined to the person or the person's immediate
surroundings (e.g., a chair or bed). No clustering of incidents by day of the week or month of the year was observed. Of 34 incidents
for which time of occurrence was known, 20 (59%) occurred between 12:00 midnight and 8:00 a.m.

In addition to the 38 fatalities, these 37 incidents resulted in 16 nonfatal injuries, which included two injuries to
firefighters, one injury to a police officer, and 13 injuries to civilians. Functioning smoke alarms were present in 19 (51%)
incidents. Sprinklers and signage indicating that oxygen was in use were noted in one (3%) incident each.

Editorial Note:

Fires associated with tobacco use are the leading cause of residential fire deaths in the United States
(4). Although smoking should never be allowed where LTOT is used
(4), a substantial percentage of persons on LTOT continue
to smoke. A precise percentage is not known; however, estimates range from 10% to 43%
(2,5,6,8). Medical oxygen can saturate clothing, fabric, and hair. Oxygen will not
explode but will act as an accelerant. A fire, such as a lit
cigarette, will burn faster and hotter in an oxygen-enriched environment.

Five case series involving patients admitted to burn centers in the United States after being injured while smoking in
the presence of medical oxygen have been published previously
(2,6). These case series involved a total of 79 in-patients and
15 deaths, for an overall mortality rate of 19%. In addition, one study indicated that 52% of all patients burned while smoking
in the presence of medical oxygen were treated at a burn center on an outpatient basis
(2). The number of fires ignited by smoking in the presence of medical oxygen in which injuries occur that do not require treatment at a burn center is unknown.

The findings in this report are subject to at least four limitations. First, electronic records maintained by state fire
marshals often do not allow for the identification of this specific type of fatality
(4). Therefore, case counts for Maine,
Massachusetts, and New Hampshire, which relied on data from state fire marshals, might represent underestimates. Second, some of
the decedents were alone at the time of the incident. Determining the exact cause of incidents without witnesses was
sometimes complicated by extensive fire damage. Third, complete information was not available for all fatalities. Some of the
factors described in this report, such as presence of signage, might represent minimum estimates of actual prevalence.
Finally, incidents without fatalities were not examined.
Focusing only on incidents with fatalities underestimates the public
health impact of smoking during LTOT.

Preventing injuries resulting from smoking in the presence of medical oxygen requires a multifaceted approach. First,
health-care providers should employ evidence-based guidelines for achieving smoking cessation
(7,8). Quitting smoking has immediate and long-term health benefits
(7) and will decrease fire risks associated with medical oxygen substantially.
Second, the need for LTOT should be carefully assessed
(5). In one study, 40% of patients on LTOT were found not to
meet established criteria for this therapy
(9). Third, strategies to prevent fire-related injuries should be emphasized. Patients
and their household contacts should be thoroughly educated about the dangers of smoking in the presence of medical oxygen.
The U.S. Fire Administration recommends that homes be equipped with smoke alarms on every level, including the basement,
and for extra safety, both outside sleeping areas and inside bedrooms
(10). Consideration should be given to installing
automatic sprinkler systems, where feasible, and families should develop a fire
escape plan and practice it several times a year
(10).

Task force on community preventive services. Zaza S, Briss PA, Harris K, eds. The guide to community preventive services: what works to
promote health? New York, NY: Oxford University Press; 2005. Available at
http://www.thecommunityguide.org/library/book.

* An oxygen concentrator or generator is a device that produces substantially higher concentrations of oxygen than is found in ambient air. It is an alternative
to tanks or cylinders of compressed oxygen for providing LTOT to patients.

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